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LRe=d <br /> 1y2y2010 2:44:28Pf <br /> SAN JO/ COUNTY,ENVIRONMENTAL HEAr�� DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 12/22/2010 Paget <br /> tion Criteria: FacilityID FA0018043 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the under 'goad owner,Operator or agent of same,acknowledge that all site'.and/or project y taality or activity will be billed to the p�"4 <br /> as[he OW on this form, r also cern gist all R J specific,PHS/EHD hourly charges associated with this <br /> State andlor Federal taws. certify operations will be performed In accordance with all applicable Ordinace Codes and/or Standards and 'I <br /> is �? ��0 <br /> APPLfCANT'S SIGNA e ! ! <br /> I <br /> Program Records to be TRAN '$25.00= Amount Paid Date 1 1 l <br /> Water ystem to beT SFERED: Amount Paid Date <br /> i Check Number Received by <br /> RENS: !� Date ! / Account out: Date <br /> ENTS: <br /> ' 1 <br /> ' I <br /> L <br /> I <br /> . l <br /> 4§ <br /> r <br /> i <br /> - t <br /> i <br />} <br /> 4. . <br /> I <br /> l <br /> 4 <br /> L <br /> S <br /> i <br /> f ❑eh-envlenvisionVeportsW21.rpt <br />